Higher P-Wave Dispersion in Migraine Patients with Higher Number of Attacks

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doi:10.1100/2012/791460

The

cientific

WorldJOURNAL

Clinical Study

Higher

P-Wave Dispersion in Migraine Patients with

Higher Number of Attacks

A. Koc¸er,

1

_{M. Eryılmaz,}

2

_{H. Tutkan,}

3

_{N. Ercan,}

2

_{and Z. S. K¨}

_uc¸¨

_ukbayrak

4

1_{Neurology Department, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey} 2_{Neurology Department, Medical Faculty, D¨uzce University, D¨uzce, Turkey}

3_{Neurology Department, Sakarya State Hospital, Sakarya, Turkey} 4_{Physiology Department, Medical Faculty, D¨uzce University, D¨uzce, Turkey}

Correspondence should be addressed to A. Koc¸er,abdulkadirkocer@yahoo.com

Received 30 October 2011; Accepted 29 November 2011 Academic Editor: Ahmet Baydin

Copyright © 2012 A. Koc¸er et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective and Aim. An imbalance of the sympathetic system may explain many of the clinical manifestations of the migraine. We aimed to evaluateP-waves as a reveal of sympathetic system function in migraine patients and healthy controls. Materials and Methods. Thirty-five episodic type of migraine patients (complained of migraine during 5 years or more, BMI< 30 kg/m2_{) and 30}

controls were included in our study. We measuredP-wave durations (minimum, maximum, and dispersion) from 12-lead ECG recording during pain-free periods. ECGs were transferred to a personal computer via a scanner and then used for magnification of x400 by Adobe Photoshop software. Results.P-wave durations were found to be similar between migraine patients and controls. AlthoughP WD (P-wave dispersion) was similar, the mean value was higher in migraine subjects. P WD was positively correlated withP max (P < 0.01). Attacks number per month and male gender were the factors related to the P WD (P < 0.01). Conclusions. Many previous studies suggested that increased sympathetic activity may cause an increase inP WD. We found that P WD of migraine patients was higher than controls, andP WD was related to attacks number per month and male gender. Further studies are needed to explain the chronic eﬀects of migraine.

1. Introduction

It is widely accepted that symptoms of migraine are related to the involvement of the autonomic nervous system, and dysfunction may aﬀect atrial and ventricular repolarization. The sympathetic nervous system is known to play an important role in the genesis of ventricular arrhythmias [1].

QT interval changes andP-wave changes may be predictors

of atrial and ventricular arrhythmias. The most significant one is prolonged QT interval, which is a predictor of

ventricular arrhythmias [2]. In addition,P-wave dispersion

which is a predictor of atrial fibrillation (AF) is defined

as the diﬀerence between maximum and minimum P-wave

duration and has been associated with inhomogeneous and

discontinuous propagation of sinus impulses [3, 4]. It has

been shown that increased sympathetic activity caused a

significant elevation in P-wave dispersion [5]. It has also

been reported that there was an association between the

autonomic nervous system and atrial fibrillation [6,7].

Although the previous reports reflected atrial and

ven-tricular repolarization abnormalities that were aﬀected by

disturbed ANS (sympathetic and/or parasympathetic ner-vous system dysfunction) during migraine attacks, the asso-ciation between atrial fibrillation and migraine is limited to case reports only [8–12]. Duru et al. reported that maximum P-wave duration (P max) and P-wave disperson (P WD) were found higher during migraine attacks than during

pain-free periods [13]. However,P WD was not reported during

pain-free period which might be a shower of damage related to attacks until now in comparison to healthy controls. In this study, we tried to find whether the patients with migraine may go under the risk of atrial and ventricular arrhythmias

or not. For this reason, we undertook evaluation ofP-wave

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2 The Scientific World Journal

Table 1: Sociodemographical and clinical variables andP-wave durations in comparison.

Variable Migraine group (n=35) Controls (n=30) P value

Age (year) 34.60±7.54 35.87±6.97 0.48

Gender 0.25

Male 6 9

Female 29 21

Number of the patients

with aura 14

without aura 21

Duration of migraine (hour) 22.43±22.85 (range: 3.0–72.0) Attack number per month 3.37±1.63 (range: 2.0–8.0)

VAS score 7.63±2.11 (range: 4.0–10.0)

P min value (ms) 41.81±8.02 42.36±8.07 0.78

P max value (ms) 95.97±12.89 91.21±10.05 0.11

P WD value (ms) 54.55±13.44 50.40±11.63 0.19

with well-defined migraine during headache-free period and compared to normal healthy controls.

2. Methods

Thirty-five episodic type of migraine patients (complained of

migraine during 5 years or more, BMI< 30 kg/m2_{), and age}

and sex-matched 30 healthy controls were included in our study.

The diagnosis of migraine was made using criteria of the International Headache Society [14]. Thirty-five subjects with migraine were evaluated during the pain-free period; 14 with migraine with aura (MWA) and 21 with migraine without aura (MWOA). We confined the study to women aged 20 to 45 years who had suﬀered from migraine for more than 1 year and had at least one migraine attack per month. The presence of other pain syndromes (e.g., chronic low back pain or chronic tension-type headache), systemic disease

(e.g., diabetes mellitus), and disorders that could aﬀect the

autonomic nervous system were exclusionary. Except for mild analgesics, all drugs were withdrawn 5 days before the

testing, and no drug, including caﬀeine, or cigarettes, was

allowed on the day of testing. The control group (n = l6)

consisted of age and sex-matched persons who were free of migraine, other chronic pain syndromes, systemic diseases,

or disorders that could aﬀect the autonomic nervous system.

These subjects were not on any medication. The study protocol was approved by the Institutional Review Board.

Autonomic tests were performed in the headache-free period. None of the subjects reported headache for at least 72 h before and after testing. Subjects were instructed to abstain from caﬀeine-containing beverages and, in the adolescents, from nicotine and alcohol for at least 24 h before the test. The examinations took place between 14.00 h and 17.00 h to avoid diurnal variation and were performed in

a warm room (24◦C). The subjects were asked to lie down

and not to move during recording. The ECG recording

was performed. Heart rate, P max and minimum P-wave

duration (P min), and P WDwere measured from 12-lead

ECG recording during pain-free periods. The diﬀerence

between the maximum and minimumP-wave duration was

defined as P WD. ECGs were transferred to a personal

computer via a scanner and then used for magnification of x400 by Adobe Photoshop software.

Intra- and interobserver coeﬃcients of variation

(stan-dard deviation [SD] of diﬀerences between 2 observations

divided by the mean value and expressed in percent) were

found as 3.7% and 3.8% forP-wave dispersion. Intra and

interobserver coeﬃcients of variation were found to be

less than 5%. All data were presented as mean value ±

SD. Comparison of clinical variables between 2 groups was performed with paired Student t-test for numeric variables

and chi-square test for categorical data. AP value < 0.05 was

considered to be statistically significant. The SPSS version 11.0 package was used in statistical analysis.

3. Results

Sociodemographical and clinical findings andP-wave values

were summarized inTable 1. Ten patients were using

Trip-tans, 10 patients were using anti-inflammatory or analgesic

agents, and 15 patients were using combinations.P min was

found to be similar between migraine patients and controls.

AlthoughP WD and P max values of migraine patients were

similar in migraine patients and healthy controls, the mean

values were higher in migraine subjects as seen inTable 1.P

WD was positively correlated withP max (P < 0.001). On the

other hand, attacks number per month (P < 0.001) and male

gender (P =0.03) were the factors related to the P WD. In

addition,P max was positively correlated with age (P < 0.05).

VAS score was higher in females (P=0.02). The presence of

aura did not aﬀect P value.

4. Discussion

Aura symptoms, gastrointestinal symptoms, and photosen-sitivity or phonosenphotosen-sitivity may be an imbalance of the

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In addition, supporting sympathetic dysfunction, the systolic blood pressure overshoot during the Valsalva maneuver was found to be decreased in migraineurs with aura [15]. Dysfunction of the ANS may aﬀect atrial and ventricular repolarization. For example, increased sympathetic activity causes increased heart rate. Therefore, disrupted autonomic innervation of the heart and coronary arteries in patients with migraine may result in possible electrocardiographic (ECG) abnormalities during headache. Some case-control studies of cardiovascular function reported both sympathetic hyperfunction [16–18] and sympathetic hypofunction [19] even using single-lead ECG monitoring during migraine compared with a pain-free period.

Reduced parasympathetic and increased sympathetic nervous system (SNS) activity can lower the threshold for atrial fibrillation. Some previous studies have reported the

association between the ANS and atrial fibrillation [20,21].

But we have limited information on the association between atrial fibrillation and migraine. Duru et al. have shown that the migraine attacks were associated with increased QTc

andP-wave dispersion compared with pain-free periods in

a recent paper. Then, they concluded that patients with migraine during attacks were associated with increased QTc

and P-wave dispersion because of a disrupted autonomic

nervous system in migraine patients [13]. However,P-wave

dispersion was not reported during pain-free period which might be a shower of damage related to attacks until now. In this study, we tried to find whether the patients with migraine may be under the risk of atrial and ventricular arrhythmias or not. For this reason, we undertook evaluation

of P-wave dispersion as a sign of autonomic dysfunction

in patients with well-defined migraine during headache-free period and compared to normal healthy controls. In

our study, we found that P max and P min were similar

between migraine patients and controls. Similarly, Aygun et al. reported that ECG abnormalities particularly PR and corrected QT (QTc) interval lengthening often were present during a migraine attack, and these abnormalities would be absent or less prominent during pain-free intervals [22]. Duru et al. also found that ECG abnormalities including P-wave dispersion were more prominent during migraine attack [13]. In addition to this previous knowledges we found

that the mean value ofP WD was higher in migraine subjects,

andP WD was positively correlated with P max.

In conclusion, we believe that increased sympathetic

activity may cause significant increase inP WD of migraine

patients. The attacks number per month and male gender are

the factors aﬀecting the P WD, so the patients with higher

numbers of attack may go under the risk of autonomic-dysfunction-related problems in the future.

References

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[21] P. Coumel, “Autonomic influences in atrial tachyarrhythmias,” Journal of Cardiovascular Electrophysiology, vol. 7, no. 10, pp. 999–1007, 1996.

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